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Abstract

Medical students' interest in global health outreach work is intense and growing. Yet, medical students' global health outreach work is fraught with ethical complexity: Students must make challenging resource allocation decisions in an unfamiliar setting while providing complicated care with evolving expertise across power gradients and geographical as well as cultural boundaries. Inadequate training in the recognition and resolution of the ethical issues inherent in this work likely endangers future service work participation and undercuts the efficacy of medical students' global health outreach work. The author describes how the medical school curriculum can empower medical students to recognize and resolve ethical issues encountered in global health outreach work.

To achieve this goal, he proposes a curriculum in the ethics of global health outreach to train students to understand (1) the ethical justifications for global health outreach work, (2) the drivers of global health disparities, (3) the key ethical issues raised by global health outreach, and (4) how to resolve ethical quandaries encountered during global health outreach work through collaboration. Beyond specific topical content, a medical school curriculum in the ethics of global health outreach should emphasize the importance of local collaboration and longitudinal mentorship of medical students. Medical school training in the recognition and resolution of the ethical issues attendant on global health outreach work prepares students not only for more sophisticated work in international settings but also for the ethical complexities of medical practice closer to home.

Medical students' interest in global health outreach work is intense and growing,1–3 spurred in part by the global HIV pandemic, the 2004 Indian Ocean tsunami, and the ongoing disasters in Haiti and Japan. Fully 63% of matriculating U.S. medical students were interested in global health outreach work according to responses on the Association of American Medical Colleges' Matriculating Student Questionnaire in 2010,4 and many medical schools and residency programs offer global health training programs.5

At first glance, passionate medical students' interest in global health outreach work is an unalloyed good: It provides a window into diverse practice environments, can solidify medical students' dedication to service work, and provides people in need with cheap but passionate advocacy and care. It is tempting to posit that the recent uptick in medical students' interest in global health outreach work is the antidote to medical students' declining interest in work with underserved populations.6–8 For instance, medical students who participated in a multidisciplinary medical trip to rural Nicaragua reported strong interest in volunteerism and renewed interest in working with the underserved.9

Challenges in Medical Students' Global Health Outreach Work

Ethical complexity

Despite its upsides, global health outreach work is conducted in a setting that, to medical students, is strange and has unfamiliar rules. Also, students working in a foreign environment can confront complicated ethical questions10: Who deserves help first? Who decides which health problem is addressed first? Do short-term student trips to exotic locations falsely reassure students that they have helped the needy while, in actuality, failing to rectify the root causes or long-term impacts of chronic health disparities? Does respect for the autonomy of the local population extend to local health care providers even if they engage in substandard medical care? Is engaging in bribery an ethically acceptable way to facilitate the goals of outreach work if bribery is culturally acceptable and prevalent in the setting? Who prevails when outreach providers and local representatives disagree about the proper allocation of resources?

Complex decisions and inadequate training

Anecdotal evidence suggests that the dawning apprehension of ethical complexities like those just outlined can, paradoxically, dampen medical students' enthusiasm for global health outreach work, especially if they feel inadequately trained to meet these challenges. For instance, nurses who experienced moral distress exhibited higher rates of burnout,11 and medical students with burnout were less likely to care for the underserved.12 More important, my experience and that of colleagues has shown that medical students who are inadequately trained to avoid the ethical pitfalls of global health outreach work can fail to make the impact they want, and may even blunder into the perpetuation of the health disparities they came to redress. The ethical delivery of global health outreach thus requires sophisticated skills in the recognition and navigation of these ethical complexities.

Despite the panoply of ethical decisions potentially confronting medical students involved in global health outreach work, in Canadian medical education a few years ago, 44% of students' international health experiences took place without faculty supervision.13 Similarly, 56% of U.S. medical students graduating in 2010 indicated that they did not participate in a structured service learning during medical school, and 40% of those graduating students felt that they received inadequate instruction in global health issues.14 These findings indicate that medical schools can do a better job preparing their students for the ethics and logistics of global health outreach work.

But how should medical schools prepare students for the huge diversity of ethical and logistical issues that can arise during global health outreach work, given that this work occurs in innumerable locations, in dizzyingly diverse and changing cultural contexts, and at both the population and individual interfaces? The best approach is to provide medical students with basic proficiency in the systematic recognition and resolution of the ethical pitfalls of global health outreach work. Below, I envision the kind of curriculum that could achieve that goal.

A Proposed Curriculum in the Ethics of Global Health Outreach Work

What is global health outreach work?

Teaching medical students to recognize and resolve the ethical pitfalls of global health outreach work requires definition of global health outreach work. Medical students travel near and far to provide innumerable varieties of clinical care and health advocacy to fight the many manifestations of poverty and need. The best definition of global health outreach work, therefore, is inclusive. Global rightly includes local because healing the sick has the same worth in inner-city Detroit as it does on the outskirts of Dar es Salaam, even if geography and culture alter the manifestations of illness and need.

A conceptual foundation for global health outreach work

To move medical students toward a more sophisticated analysis of the ethical ramifications of global health outreach work, the ideal curriculum starts with training in the ethical motivations to heal the sick and disadvantaged. This naturally leads to a discussion of the economic, political, and cultural forces that lead to global health disparities. This conceptual foundation supports a survey of ethical global health outreach work that, if paired with specific training in collaboration and community building, can promote the ethical provision of global health outreach work. See Figure 1 for a graphical depiction of these conceptual foundations of a curriculum in the ethics of global health outreach work, discussed below.

Justifications for global health outreach work.

Most matriculating medical students are very idealistic. Yet the demands of career, finances, family, and sleep combined with a growing understanding of the ethical and logistical complexities of global outreach work can impede medical students' transition into lifelong service work. These life challenges can overcome students' motivation to participate in outreach work if students lack an explicit ethical foundation for idealism. Therefore, a comprehensive medical school curriculum in global health outreach work should articulate the ethical underpinnings of global health outreach work, including instruction in the major bioethics tenets of beneficence, nonmaleficence, and justice.15 If solely abstract, principles like these can be insufficient to motivate lifelong service work, so a key component of the early curriculum on the justifications of global health outreach work is in-person exposure to health care disparities. Face-to-face contact with real-world and tractable injustice can stoke the desire to serve and can allow a student to gain the skills to have a very real and personal impact on health disparities, whether near home or abroad.

Sources of health disparities.

Although traditionally absent from the medical school curriculum, training in the recognition of the societal sources of health disparities can empower medical students to be more effective at redressing the root causes of the health disparities they see in clinic and on the wards. As a result, the Society of General Internal Medicine issued formal guidelines in 2007 advocating for the inclusion of health disparities training in medical school curricula.16 Although the epidemiology of health disparities is not itself an ethics topic, it necessarily begets consideration of the proper allocation of resources, justice, and the impact of systematic injustice on personal health autonomy. This portion of the curriculum on the ethics of global health outreach, which should not overshadow the clinical content of the medical school curriculum, integrates well with public health components of the existing medical school curriculum.

Key ethical challenges in global health outreach work.

Medical students' global health outreach work occurs at the intersection of key tenets in biomedical ethics and major schools of ethical thought (illustrated in Figure 2). Key tenets in biomedical ethics apply to global health outreach: respect for autonomy, nonmaleficence, beneficence, and justice.15 In the cross-cultural provision of medical care, patient autonomy is necessarily endangered by illness, by language barriers, by unrecognized and/or unshared cultural assumptions, and, thus, by the external imposition of priorities for health interventions. The principle of nonmaleficence, too, is endangered by multiple factors. The time-limited provision of unintentionally substandard care by medical students can risk harm to local populations, harm that can be compounded by challenges to the provision of optimal surveillance for missed diagnoses and treatment complications. Beneficence is integral to global health outreach work but is not uncommonly joined by (even diluted by) competing implicit or explicit motivations of medical students, such as resumé building and career tourism.17 Lastly, although justice is inarguably served when redressing health disparities, the societal injustices that give rise to health disparities in the first place can be overlooked by medical groups with inadequate time or training to understand the larger local political calculus.

Everyone engaged in global health outreach work faces these ethical complexities. Some sources of ethical complexity during global health outreach work are intensified for medical students. These include working along power gradients, border crossings, tight time commitments, and evolving expertise.

Working along a power gradient. When comparably wealthy and increasingly well-educated medical students journey to poorer locales to work with their less-well-educated peers, they work in a power gradient. These one-on-one interactions are the soul of service work and an opportunity for students to form solidarity with the people they serve,18 but juxtapositions in power and wealth can lead to misunderstanding, coercion, and delicate cross-cultural miscommunications. For example, students on short-term medical missions who impose medical interventions without consulting with local community representatives may beget mistrust and incomplete local engagement in care.

Border crossings. Global health outreach work brings medical students to unfamiliar linguistic and cultural territory, whether it occurs in an exotic locale or an unfamiliar context closer to home. This can be exciting and instructive for medical students, but in such unfamiliar territory decisions about complex ethical issues like respect for patient privacy and resource allocation can be fraught if students are ill informed about local, culturally determined health priorities. For example, HIV/AIDS prevention work that ignores patient privacy concerns, local sources of stigma, and local behavioral drivers of the HIV epidemic is unlikely to succeed.

Time commitments. Most medical students engage in global health outreach work for short periods amid tightly constrained schedules. Yet, few global health crises are amenable to short-term interventions. Therefore, there is an intrinsic danger that short-term global health outreach missions will bring little benefit to the population they believe they have served.19 This dynamic can become increasingly problematic as maturing medical students juggle busy careers and increasing personal commitments such as marriage and parenthood.

Evolving expertise. Medical students' provision of clinical services during global health outreach work implies the provision of clinical care that is typically less sophisticated than that provided by a fully trained physician. This care is a critical resource in underserved areas, and, with careful planning and supervision, the quality of medical students' care can even exceed that provided by attending physicians. Yet, the provision of care by medical students with evolving health care expertise does carry a risk of institutionalizing a low upper limit of quality of care.9

Relevant ethical schools of thought.

Because of the locally specific and endlessly diverse ethical complexities of medical students' global health outreach work, the associated ethical challenges defy easy resolution by a single ethical school of thought. Utilitarian ethics argues for the provision of the best medical care to the greatest number of patients, but respect for individual autonomy, beneficence, and altruism trigger a countervailing desire to do everything possible for the patient who is here now. How should a medical student trying to do good work in a strange land balance these competing ethical priorities? Although altruism is a major motivator of medical students' global health outreach work, the concrete realization of altruistic beliefs can be hindered by the students' potential ignorance of local epidemiology and the population's health priorities. Deontological ethics argues that ethical behavior is governed by adherence to ethical rules and values such as the provision of equal care to all, whereas consequentialist ethics judges the ethics of an action on its impact on the world. Although acting on dedication to equal care for all motivates much of medical students' global health outreach work and, thus, is justifiable from a deontological standpoint, from a consequentialist standpoint the impact of medical-student-driven global health outreach work can be small and even averse at an individual level if handled unethically.

How to address key ethical challenges in global health outreach work.

Because single ethical precepts can provide conflicting guidance, a method of resolution of such ethical quandaries is required to allow transparent, defensible, and confident decision making. Fortunately, approaches to the systematic resolution of ethical issues have already been clearly articulated in clinical bioethics20,21 and international research22 and are adapted for global health outreach work, as shown in List 1. These approaches should be taught in the formal medical school curriculum to enable medical students to resolve ethical conundrums that arise in both domestic and international settings for the provision of global health outreach work.

The importance of collaboration.

Quick-witted and passionate medical students freshly armed with epidemiological data can, when sensitized to the ethical issues inherent in global health outreach work, make snap decisions about the best harmonization of these complex concerns without consulting the most important source of information: the people they serve. Yet, any approach to the resolution of the ethical complexities of global health outreach work is necessarily incomplete until there has been clear collaboration with the local population most impacted by global health outreach.3 One reason for this is that although all outreach sites share common ethical issues, ethical issues can be locally specific or, at the very least, nuanced by local culture and belief. Beyond simple engagement, ongoing local community representation and collaborative dialogue promote locally and culturally appropriate approaches to evolving ethical questions that arise during shared global health outreach work. One benefit of long-standing collaborative dialogue with local community representatives is the acquisition of an improved understanding of key cultural concerns that likely impact local ethical decision making.

In this cross-cultural context, differences may arise regarding the proper prioritization of resource allocation in outreach work. Local representatives, for instance, may suggest intervention around a health topic that seems to be a lower-priority issue to a U.S. group aware only of the health epidemiology of the host country. After vigorous cross-cultural dialogue factoring in epidemiological and medical concerns, deference should be given to local priority rankings. Such a community-based participatory approach not only ranks health interventions in a culturally appropriate fashion that ethically respects the autonomy of the locals but also improves longer-term collaboration between locals and visitors and, thus, the ongoing efficacy of present and future health interventions.23

Indispensability of mentorship.

No medical school curriculum can anticipate every ethical complexity encountered in the myriad sites of global health outreach work. Still further, the vicissitudes of global health outreach work can preclude in-depth, on-site, abstract discussion of relevant ethical precepts.5 As a result, longitudinal, on-site mentorship is a critical component of a complete curriculum in the ethics of medical students' global health outreach. The mentorship carried out by a senior physician with experience in global health outreach work can help translate abstract ethical principles into living solutions to complex, real-world problems. Beyond ongoing, on-site mentorship, one valuable venue for such mentorship is postoutreach debriefing.

Steps Toward Curriculum Implementation

Crump and Sugarman24 outlined the steps that institutions should take to support medical students' ethically sound involvement in global health outreach. This article complements that invaluable resource by detailing the specific ethical issues students face and providing an explicit, teachable system for their recognition and resolution.

List 2 states key components of a medical school curriculum in the ethics of global health outreach work. Although a medical school curriculum of this type is vitally important at institutions where many students participate in international health outreach, there is substantial overlap with the ethical issues covered regarding domestic outreach; thus, most schools should include some relevant materials in the standard curriculum. Many medical schools offer more intensive experiences in global health for interested students, and these dedicated global health curriculum tracks are another suitable home for such material.

Generalizability of a Global Health Ethics Curriculum

Because global health outreach includes outreach done in domestic settings, even students who never travel overseas will confront ethically complex decisions about resource allocation, cross-cultural communications, and structural threats to patient autonomy. As a result, much of the material central to a global health ethics curriculum for medical students has wide applicability to all students. One implementation challenge is to choose which portions of the global health ethics curriculum should be taught to all students, with an emphasis on how a portion's utility transcends geography, and which should be available to students with a special interest in global health outreach work. Different institutions may choose a different balance of the two approaches depending on student body and faculty interests, but the provision of a standard core curriculum in the ethics of global health outreach should be an important part of modern medical training.

Conclusions and Future Directions

The implementation of an explicit medical school curriculum that prepares students to face the ethical complexities of global health outreach work is likely to enhance the efficacy of medical school graduates' participation in global health outreach work. Formal research should test the validity of this assertion and should investigate which components of the curriculum best prepare graduates for the increasingly complicated work of preventing and treating illness around the world.

Acknowledgments:

This article benefits from the insightful comments of James Bernat, Lisa Adams, and John Butterly, and the fascinating conversations of the Dartmouth Medical School Social Justice Vertical Integration Group.

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